MEDICARE: GREGORY J DAHL DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2647	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62506DA	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1164435517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY J DAHL DC

Provider Business Mailing Address
First Line	:	PO BOX 19252
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55419-0252
Country	:	US
Telephone Number	:	612-823-1702
Fax Number	:	612-823-5116

Provider Business Practice Location Address
First Line	:	ONE GROVELAND TERRACE
Second Line	:	#202
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-1174
Country	:	US
Telephone Number	:	612-823-1702
Fax Number	:	612-224-9817

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	06/04/2015

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